Provider Demographics
NPI:1265544340
Name:SMITH, THEODORE G (DC)
Entity type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:G
Last Name:SMITH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:639 OLD PHOENIX RD
Mailing Address - Street 2:
Mailing Address - City:EATONTON
Mailing Address - State:GA
Mailing Address - Zip Code:31024-5610
Mailing Address - Country:US
Mailing Address - Phone:706-485-1010
Mailing Address - Fax:706-485-1019
Practice Address - Street 1:639 OLD PHOENIX RD
Practice Address - Street 2:
Practice Address - City:EATONTON
Practice Address - State:GA
Practice Address - Zip Code:31024-5610
Practice Address - Country:US
Practice Address - Phone:706-485-1010
Practice Address - Fax:706-485-1019
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALIC5766111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP4291Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER
GAU63241Medicare UPIN
GA35ZCGGQMedicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER